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Pharmacy Prior Authorization

Point of Sale (POS) Pharmacy Drug Prior Authorization Instructions – (click here for instructions)

Change Healthcare is the MS DOM vendor for Fee For Service drugs billed through the POS venue. If you are a Mississippi Medicaid prescriber, please submit your Fee For Service prior authorization requests through the Change Healthcare web portal, or please contact the Change Healthcare Pharmacy PA Unit at the following:

Toll-free: 877-537-0722
Fax: 877-537-0720

For MSCAN drug prior authorizations, please click here for MSCAN plan prior authorization contact information.

Please utilize the drop-down menus below to select the appropriate PA packet.

Prior Authorization Packets

Prior Authorization Packets Updated
Brand Name Multi-Source 6/21/2019
Early Refill 6/21/2019
Enteral Nutrition 6/21/2019
EPSDT – Beneficiaries Under 21 6/28/2019
Growth Hormone 10/1/2021
Hepatitis C Therapy 3/1/2022
Max Unit Override 6/21/2019
Multiple Concurrent Antipsychotics for Beneficiaries (Age < 18) 6/21/2019
Opioid Packet – Effective 8/1/2019       FAQs 9/10/2019
PDL Exception Request 6/21/2019

Mississippi Medicaid coverage of Synagis for the 2021-2022 RSV season will end on March 31, 2022

Universal Prior Authorization Form 6/21/2019

Manual PA Criteria

Please utilize the appropriate PA form listed under Prior Authorization Packets in drop-down menu above. 

Manual Prior Authorization Criteria Updated
Akynzeo 2/3/2020
Antipsychotics 2/3/2020
Austedo 6/10/2020
CGRPs 5/26/2021
Corlanor 2/3/2020
Cresemba 2/3/2020
Dupixent – Asthma 2/3/2020
Dupixent – Atopic Dermatitis 2/3/2020
Dupixent – Nasal Polyposis 12/27/2021
Emflaza 4/28/2022
Endari 2/3/2020
Eucrisa 4/1/2020
Evrysdi 4/6/2021
Exondys 2/3/2020
Farydak 2/3/2020
Hemlibra 2/3/2020
Ingrezza 2/3/2020
Jadenu 2/3/2020
Juxtapid 2/3/2020
Kalydeco 1/27/2021
Lotronex 2/3/2020
Lynparza 6/3/2020
Mavenclad 2/3/2020
Mayzent 2/3/2020
Ocrevus 2/3/2020
Orkambi 2/3/2020
Oxbryta 5/9/2022
Palforzia 12/16/2020
Praluent 10/27/2019
Probuphine 2/3/2020
Repatha 10/16/2019
Sivexto 2/3/2020
Stribild 2/3/2020
Sublocade 2/3/2020
Symdeko 1/27/2021
Trikafta 7/9/2021
Tybost 2/3/2020
Varubi 2/3/2020
Viltepso 1/21/2021
Vivitrol 2/3/2020
Vyepti 2/10/2021
Vyondys 53 1/22/2021
Zontivity 2/3/2020
Zyvox 2/3/2020

Physician Administered Drug (PAD) Prior Authorization Instructions

Alliant Health Solutions is the current vendor responsible for prior authorization requests for fee-for-service (FFS) Medicaid beneficiaries. Please click here to direct you to the Alliant official website, or call Alliant directly at 1-888-224-3067.  Providers are encouraged to register with Alliant as soon as possible to submit authorization requests via the Alliant web portal. Drug criteria may be found on the Help/Support page. For a listing of drugs that require a PA, please click one of the options below.

  • All Physician Administered Drugs which require PA by Alliant: PDF  |  Excel

Miscellaneous Forms

Pharmacy Reconsideration Request Form

MedWatch Form